FTC gave GRIPA OK, but payers won’t play
Payers hesitant about buying IPA model
Healthcare could look like this.” That’s the trademarked slogan used on the website for the Greater Rochester Independent Practice Association. Some might argue that the slogan should be: “Healthcare could look like this—if only the Greater Rochester Independent Practice Association had some health plan contracts.”
GRIPA, an organization that includes 812 physicians and their affiliate hospitals: 494-bed buy it,” said David Narrow, an attorney in the healthcare division of the FTC Bureau of Competition.
The Rochester market is dominated by two payers—Excellus Blue Cross and Blue Shield and MVP Health Care—and some observers have blamed GRIPA’s small client base on the payers dragging their feet. Eric Nielsen, GRIPA chief medical officer, doesn’t necessarily disagree. “That’s not wrong, payers have been dragging their feet,” Nielsen said, adding that executive looking elsewhere now and has sought to “create diversity” in the market by recruiting three new Medicare Advantage plans to do business in the area and is looking to add more self-insured large employers, he said.
“We have several other contracts pending,” he said. “We had hoped to get employers to approach the payers and they said, ‘Why bother? Just go to us directly.’ ” Nielsen said about 35% of the community’s physicians are affiliated with GRIPA, but the IPA contract for clinical integration is nonexclusive so payers go around the organization and contract individually with its doctors.
GRIPA members use a secure, Health Insurance Portability and Accountability Act of 1996-compliant physician Web portal and database to share and store patient information—including clinical data from office visits and hospitalizations, laboratory results, and diagnostic imaging, Nielsen said. And, he said, that the database is then used to generate physician quality reports on preventive medicine and care management according to physiciancreated, evidence-based guidelines.
In theory and according to FTC belief, this approach will improve outcomes and lower costs, but Nielsen acknowledges their small client base has not yielded enough data to prove their case, which has also hindered GRIPA’s growth. “If they insist on seeing outcomes data before the contract with us, it’s a Catch-22,” he said. “But we don’t have a lot of data, because we don’t have a lot of members.”
In contrast, Oak Brook, Ill.-based Advocate Physician Partners, which is believed to be the largest clinically integrated IPA with some 3,400 doctors and eight hospitals, has five years of “value reports” posted on its website. According to the 2010 report, the clinical integration program’s asthma outcomes initiative saved $16 million based on national cost averages and resulted in an estimated 37,920 days saved from absenteeism and lost productivity. The report also states that the organization’s generic drug-prescribing initiative saves payers some $14.8 million annually.
Advocate Physician Partners has contracts with 10 payers in the market. Mark Shields, Advocate vice president for medical management, said the group has been encouraged by the FTC to talk about its program with providers and policy makers. Shields said that doctors are not allowed by the FTC to work together on setting prices for services—unless they are sharing financial risk or they are clinically integrated and working together to “add value to the marketplace” by increasing quality and lowering costs.